From the Guidelines
For a scaphoid fracture with possible avascular necrosis, immediate orthopedic consultation and surgical intervention are recommended to prevent long-term complications and preserve wrist function. The primary treatment is typically open reduction and internal fixation (ORIF) with bone grafting, as scaphoid fractures have a high risk of avascular necrosis due to the bone's retrograde blood supply 1.
Specific Treatment Steps
- Immobilize the wrist with a thumb spica splint until surgery.
- Schedule urgent orthopedic evaluation, ideally within 24-48 hours.
- Obtain advanced imaging (MRI or CT) to assess fracture pattern and vascular status, as either CT without IV contrast or MRI without IV contrast is usually appropriate in this scenario 1.
- Proceed with surgery: ORIF with headless compression screw and vascularized bone graft.
- Post-operative care includes cast immobilization for 6-12 weeks, followed by physical therapy.
Medication Regimen
- Pain management: Ibuprofen 400-600mg every 6 hours as needed, or
- Acetaminophen 500-1000mg every 6 hours if NSAIDs are contraindicated
- Consider short-term opioids (e.g., hydrocodone/acetaminophen 5/325mg every 4-6 hours) for severe pain
Early surgical intervention with vascularized bone grafting can improve blood flow to the fracture site, promoting healing and reducing the risk of non-union or collapse 1. Prompt treatment is crucial to preserve wrist function and prevent long-term complications, such as osteoarthritis and chronic pain. The risk factors for osteonecrosis, including trauma, corticosteroid therapy, and alcohol use, should also be considered in the management of scaphoid fractures 1.
From the Research
Implications of Scaphoid Fracture with Possible Avascular Necrosis
The implications of a scaphoid fracture with possible avascular necrosis are significant and can lead to various complications. Some of the key implications include:
- Nonunion of the fracture: Avascular necrosis can lead to nonunion of the fracture, which can result in chronic pain, limited mobility, and decreased grip strength 2, 3.
- Limited treatment options: If avascular necrosis is suspected, treatment options may be limited, and surgical intervention may be necessary 3.
- Poor prognosis: A decreased signal intensity from the proximal pole of the scaphoid on magnetic resonance imaging may indicate a poor prognosis, with only a limited number of patients achieving healing of the fracture even with bone grafting and internal fixation 4.
- Late onset of symptoms: Avascular necrosis can occur even after apparent healing of the fracture, with symptoms appearing months or even years after the initial injury 5.
- Diagnostic challenges: Vascular compromise in the scaphoid can be difficult to diagnose, with non-specific findings on plain radiographs and computed tomography, highlighting the importance of advanced imaging techniques such as magnetic resonance imaging 2, 3.
Treatment Options
Treatment options for scaphoid fractures with possible avascular necrosis vary depending on the individual case and may include:
- Conservative treatment: In some cases, particularly in children, conservative treatment with immobilization may be sufficient to achieve healing, even in the presence of avascular necrosis 6.
- Surgical intervention: In other cases, surgical intervention may be necessary, with options including vascularized bone grafts, bone morphogenic protein, and limited wrist arthrodesis 3.
- Advanced imaging: The use of advanced imaging techniques such as magnetic resonance imaging and computed tomography can help diagnose vascular compromise and guide treatment decisions 2, 3, 4.